p.1

Introduction to nutrition
Feeding Hospitalized Dogs & Cats
Nutrition series – 3
Dr. Sarah Wilson

p.2

Feeding hospitalized dogs & cats - Outline
- Importance of feeding hospitalized patients
- Patient assessment
- Healthy vs sick hospitalized patients
- When to give nutritional support
- How to give nutritional support
- Feeding & diet options
- Complications & monitoring
Note: No conflicts to disclose. Any images of specific diets are not an endorsement of that specific food or company – simply a visual aid
Image property of Dr. Wilson

p.3

Why nutrition in hospital is important
- Malnutrition in hospital patients is common
- Imbalanced intake of protein &/or calories to support tissue metabolism
- Investigation of the relationship between caloric intake and outcome in hospitalized dogs – multi-center study in dogs; Remillard et al. 2001
- Evaluated written orders for patients & intake to determine if patients in negative energy balance (i.e. adequate intake in hospital = Resting energy req. RER)
- 276 dogs over 821 full hospitalization days – only 27% had intake >95% RER
- 22% - poorly written orders
- 34% - orders to withhold food (50% due to pre-surgical recommendations)
- 44% - dogs refused to eat adequately

p.4

Why nutrition in hospital is important
- Prevent malnutrition (generally accepted rule) – determine RER on hospital admission and establish nutritional support within 24 hours if voluntary intake is inadequate
- Consequences of malnutrition are significant
- Decreases tissue synthesis and repair – consider wound healing!
- Decreased immunocompetence
- Impaired intestinal barrier function and organ function
- Altered drug metabolism – increase or decrease therapeutic effect
Image property of Dr. Wilson

p.5

Patient assessment
- Patient assessments happen on every patient entering the hospital
- Include nutritional assessment & calculating RER (70*BW0.75)
- Allows us to develop appropriate hospital feeding orders
- How much to feed
- What to feed
- Route
- Plan/orders
- Monitoring
Images property of Dr. Wilson

p.6

Patient evaluation
- Physical Examination
- TPR, pain, nutrition
- Body Weight & Body Condition Score (BCS) – every day while in hospital
- Indicate BCS scale (i.e. 5/9)
- Muscle Condition Score (MCS)
- Normal, mild, moderate & severe muscle loss
Images from: https://wsava.org/WSAVA/media/Documents/Committee%20Resources/Global%20Nutrition%20Committee/English/Body- Condition-Score-cat.pdf & https://wsava.org/WSAVA/media/Documents/Committee%20Resources/Global%20Nutrition%20Committee/English/Body- Condition-Score-dog.pdf
Image from: https://www.wsava.org/WSAVA/media/Documents/Committe e%20Resources/Global%20Nutrition%20Committee/English/ Muscle-Condition-Score-Chart-for-Dogs.pdf & Cats.pdf

p.7

Nutritional assessment
- Patient evaluation & diet history
- Why diet history?
- Establish a baseline for your patient
- Estimate caloric intake
- Determine high risk feeding
-Inappropriate diet – Vet tx, raw*, home-cooked diets, treats/ supplements/ medications
Image from: https://www.wsava.org/ WSAVA/media/Documents/Committee%20Resour ces/Global%20Nutrition %20Committee/English/ Diet-History-Form.pdf

p.8

Raw diets in hospital - Considerations
- Zoonotic risk
- Campylobacter, Clostridium, Escherichia coli, Listeria, Staphylococcus (enterotoxigenic), Salmonella, Toxoplasmosis etc.
- Can shed bacteria or oocysts although asymptomatic
- Consider liability
- Other immunocompromised patients, staff health, possible loss of income due to hospital closure
- Hospital policy necessary – have protocols for handling, storage, patient management, cleaning & biosecurity
Image property of Dr. Sarah Wilson

p.9

CVMA Position statement
Position
The Canadian Veterinary Medical Association (CVMA) and the Public Health Agency of Canada (PHAC) believe that there is a body of evidence supporting the potential health risks for pets fed raw meat based diets, and for humans in contact with either raw meats or pets fed a raw meat diet.
The CVMA holds that the documented scientific evidence of potential animal and public health risks in feeding raw meats outweigh any perceived benefits of this feeding practice.
The CVMA advises veterinarians that do recommend raw meat diets for pets under their care to be aware of potential liability concerns should a pet or in-contact human become ill due to pathogens originating in the diet.
The CVMA advocates that veterinarians recommending raw food diets must inform pet owners of potential risks (Background 3) and educate the owners on how to mitigate the real risk of pathogen exposure in both handling the food and in managing pets consuming raw meat diets.

p.10

Feeding hospitalized patients
Patient assessments happen on every patient entering the hospital
- Include nutritional assessment
Allows us to develop appropriate hospital feeding orders
- How much to feed
- What to feed
- Route
- Plan/orders
- Monitoring
Patient in hospital is assessed into two groups:-
1) Healthy
a) Medical orders – Include feeding orders
2) Sick
a) Eating
i) Adequate & appropriate intake
ii) Inadequate intake
b) Not eating
i) Medical orders - Supportive nutrition necessary

p.11

Assessing hospitalized patients for feeding
Healthy
- In hospital for elective surgery
- No underlying systemic disease
- No concerns from owners
- Eating well, no unintentional weight change, no V/D, etc.
- No concerns with your clinical evaluation
- Hx, PE, diagnostics
Sick
- In hospital due to underlying disease/ emergency
- Discuss in two groups
- Eating
- Adequate vs. inadequate intake
- Not eating

p.12

Feeding healthy hospitalized dogs & cats
Assessment on patients in hospital is done in two ways:-
Healthy
Medical orders - include feeding orders

Sick
a) Eating
i) Adequate & appropriate intake
ii) Inadequate intake

b) Not eating
i)Medical orders - Supportive nutrition necessary

p.13

Feeding healthy hospitalized dogs & cats
- Review Nutrition series 2 – Feeding Healthy Dogs & Cats
- Evaluate patient with physical examination and nutritional assessment
- Determine plan (feeding orders) & RECORD in medical record
- Determine individual patient needs
- Based on duration of stay/ reason for hospital stay - TPLO, neuter, other
- RER vs. MER vs. actual intake

p.14

- Resting Energy Requirements (RER) – the energy needed for a normal unfasted animal at rest under normal temperature conditions
- Most sick hospitalized patients should be fed RER to start
- May need to gradually work up to RER
- Maintenance Energy Requirements (MER) – the energy needed to keep an animal in a maintenance state
- Includes activities necessary for work, growth, reproduction, lactation
- Some healthy hospitalized patients may appropriately be fed MER

p.15

Energy requirements - MER
MER = RER(70 x BW0.75) x Factor =
estimate of maintenance energy requirement
Canine
- Intact Adult 1.8
- Neutered Adult 1.6
- Puppies < 4mos 3.0
- Puppies >4 mos 2.0
- Low activity 1.4
- Weight loss 1.0
- Critically ill 1.0

Feline
- Intact Adult 1.4
- Neutered Adult 1.2
- Kittens < 4mos 3.0
- Kittens >4 mos 2.0
- Low/No activity 1.0
- Weight loss 0.8-1.0
- Critically ill 1.0

p.16

Monitoring – healthy hospitalized patients
- Monitor while in hospital and include in record
- Complete feeding orders
- Weight, body condition, muscle mass
- Goal - weight stability while in hospital
- Feed intake & refusal
- Record intake clearly ex:
- 0 = ate none, 1 = ate 25% or less, 2= ate 26-50%,
3 = ate 51-75% , 4 = ate more than 75%
- Ensure patients are at least consuming RER

Feeding orders include:
- Type of food
- Amount
- Frequency
- Other (route, rate, etc.)
- What to do if refusal occurs
- Monitoring of intake

p.17

Feeding sick hospitalized patients
Patients in hospital due to emergency &/or underlying disease
Eating
- Patients are eating according to owners
- Calorie & protein intake adequate
- Diet appropriate
- Appropriate diet for disease
- Other risks?
Not-eating
- Patients are not eating at all or have inadequate intake
- Determine duration of hyporexia or anorexia
- When to intervene
- Re-feeding syndrome

p.18

Feeding healthy hospitalized dogs & cats
Assessment on patients in hospital is done in two ways:-
Healthy
Medical orders - include feeding orders

Sick
a) Eating
i) Adequate & appropriate intake
ii) Inadequate intake

b) Not eating
i)Medical orders - Supportive nutrition necessary
Images property of Dr. Wilson

p.19

Feeding sick hospitalized dogs & cats
- Patients that have underlying disease and are eating – determine if they have adequate intake
- Weight stable at an appropriate BCS & MCS
- Appropriate diet choice – Balanced diet vs. Vet Rx Diets, feeding type/strategy (canned, highly digestible)

Feeding healthy hospitalized dogs & cats
Assessment on patients in hospital is done in two ways:-
1) Healthy
Medical orders - include feeding orders

2) Sick
a) Eating
i) Adequate & appropriate intake
ii) Inadequate intake
b) Not eating
i)Medical orders - Supportive nutrition necessary
Images property of Dr. Wilson

p.20

Many veterinary therapeutic diets available to help manage diseases
- Chronic kidney disease +/- proteinuria
- Liver disease
- Gastrointestinal diseases
- Nonnspecific, IBD, PLE
- Food allergy
- Urinary disease (stones: struvite, CaOx, urate, cystine)
- Pancreatitis/ hyperlipidemia
- Obesity
- Orthopedic disease
- Short bowel
- Cardiovascular disease
- Diabetes Feeding
- Multifunction diets
Feeding Orders include:
- Type of food

p.21

Feeding orders
-Type of food
- Amount
- Frequency
- Other (route, rate, etc.)
- What to do if refusal occurs
- Monitoring of intake
Images property of Dr. Wilson

p.22

Assessment on patients in hospital is done in two ways:-
1) Healthy
a) Medical orders - include feeding orders

2) Sick
a) Eating
i) Adequate & appropriate intake
ii) Inadequate intake
b) Not eating
i)Medical orders - Supportive nutrition necessary
Images property of Dr. Wilson

p.23

When to give nutritional support – Feeding sick hospitalized dogs & cats
- Identify and address barriers to intake
- Appropriate & appetizing food, pain management, nausea, appetite stimulants, gastric protectant, additional stressors, physical barriers
- Identify and address barriers to intake
- Intervene:
- Anorexia/hyporexia 3-5 days (include days at home)
- Sooner if poor BCS, adequate voluntary intake is unlikely, marked muscle atrophy, involuntary weight loss of > 10%

Assessment on patients in hospital is done in two ways:-
1) Healthy
a) Medical orders - include feeding orders

2) Sick
a) Eating
i) Adequate & appropriate intake
ii) Inadequate intake
b) Not eating
i)Medical orders - Supportive nutrition necessary
Images property of Dr. Wilson

p.24

When to give nutritional support – Feeding sick hospitalized dogs & cats
- Identify and address barriers to intake
- Intervene:
- Anorexia/hyporexia 3-5 days (include days at home)
- Sooner if poor BCS, adequate voluntary intake is unlikely, marked muscle atrophy, involuntary weight loss of > 10%

Assessment on patients in hospital is done in two ways:-
1) Healthy
a) Medical orders - include feeding orders

2) Sick
a) Eating
i) Adequate & appropriate intake
ii) Inadequate intake
b) Not eating
i)Medical orders - Supportive nutrition necessary
Images property of Dr. Wilson

p.25

How to give nutritional support – Feeding sick hospitalized dogs & cats
- Consider overall status – adequate hydration, pain management, electrolyte/acid-base status, hemodynamically stable
- Consider gastrointestinal status – if the gut works – use it!
- Enteral feeding vs. parenteral feeding

p.26

How to give nutritional support
- Assisted feeding is required when the patient does not achieve RER with voluntary oral intake
- Multiple different options available to provide nutritional support

Assisted Feeding
- Enteral
i) NE tube
ii) E tube
iii) G tube
iv) J tube

- Parenteral
i) CPN
ii) PPN

p.27

How to give nutritional support
Enteral
- Physiologically superior
- Cheaper
- Safer
- Complete and balanced
- Long term options available
- Maintains enterocyte health
- Use some options at home*

Parenteral
- Intravenous nutrition – non-physiologic
- Expensive – formulation, materials, preparation, & monitoring
- Not balanced
- Short term in hospital use only
- More risk of complications
- Bacterial translocation
- Trickle feeding for enterocyte health

p.28

How to give enteral nutritional support
- Enteral feeding options
- Nasoenteral tube (NE tube)
- Esophagostomy tube (E-tube)
- Gastrotomy tube (G-tube)
- Jejunostomy tube (J-tube)
Image from: https://irockdecals.com/boxer-dog-outline-decal-sticker/

p.29

How to give enteral nutritional support
- Enteral feeding options
- Nasoenteral tube (NE tube)

NE TUBE
- Duration: Short term (less than a week)
- Diet type: Liquid only Image from: Nutritional management of hospitalized small animals
- Size: < 8 French
- Advantages: Non invasive, no anesthesia necessary, easy to place, cheap, voluntary intake still possible
- Disadvantages: Need for e- collar/irritating, short term & diet constraints due to small diameter
1 French = 0.33 mm (external measurement)

p.30

Nasoenteral tube placement
- Materials needed:
- Sedation
- Tube (red rubber, PVC, silicon)
- Lidocaine gel
- Proparacaine drops
- Empty syringe & sterile saline syringe
- Suture & or staples
- E-collar
- Radiology equipment – to verify placement
Image from: Small Animal Clinical Nutrition – 5th Ed.

p.31

How to give enteral nutritional support
- Enteral feeding options
- Nasoenteral tube (NE tube)
- Esophagostomy tube (E-tube)
- Gastrotomy tube (G-tube)
- Jejunostomy tube (J-tube)
E-TUBE
- Duration: Longer term (weeks to months*)
- Diet type: Slurry (can or dry +/- water)
- Size: 10-18 French
- Advantages: Easy to place & manage, can be sent home (give demonstrations & instructions), voluntary intake still possible, relatively cheap/ low risk
- Disadvantages: Invasive, requires anesthesia - perception

p.32

Esophagostomy tube placement
- Materials needed:
- General anesthesia
- Surgical preparation of site (left)
- Curved forceps (Carmalt or similar)
- Surgical blade
- Tube (red rubber, silicon) & adapter if necessary (ex. Christmas tree)
- Suture material
- Bandage material or wrap
- Radiology equipment – to verify placement
Images property of Dr. Wilson

p.33

Esophagostomy Image from: Small Animal Clinical Nutrition – 5th Ed.
Describes how to perform E-tube placement
Images property of Dr. Wilson

p.34

How to give enteral nutritional support
- Enteral feeding options
- Nasoenteral tube (NE tube)
- Esophagostomy tube (E-tube)
- Gastrotomy tube (G-tube)
- Jejunostomy tube (J-tube)

Describes how to perform G-tube placement

p.35

How to give enteral nutritional support
How to give enteral nutritional support
- Enteral feeding options
- Nasoenteral tube (NE tube)
- Esophagostomy tube (E-tube)
- Gastrotomy tube (G-tube)
- Jejunostomy tube (J-tube)

J-TUBE
- Duration: Short term (in hospital use)
- Diet type: Liquid – elemental diets
- Size: <8 French
- Advantages: Provides enteral nutrition to jejunum (bypass pancreas, stomach & duodenum)
- Disadvantages: narrow lumen - dietary limitations & rate of infusion (CRI), expensive & surgical placement & expertise required

p.36

Parenteral Nutrition
- Intravenous nutrition – partial nutrition
- Typically composed of:
- Protein - amino acid solutions
- Lipid – fatty acid emulsions
- Carbohydrates – dextrose
- +/- Vitamins & electrolytes – K, phos, B-vitamins
- Missing: trace minerals & some vitamins
Image from: Nutritional Management of Hospitalized Small Animals

p.37

How to give nutritional support
- Parenteral feeding options
- Central parenteral nutrition (CPN)
- Peripheral parenteral nutrition (PPN)

CPN
- Duration: Short term (in hospital use)
- Osmolarity: 1400 mOsm/L
- Advantages: Higher osmolarity more likely to meet calorie needs, bypass GI tract
- good for patient where enteral feeding is contraindicated (obtunded, comatose, anesthetized/ on respirator, severe GI dysfunction)
- Disadvantages: expensive & central line placement required – dedicated line, risk of complications (metabolic, infectious & mechanical)

p.38

How to give nutritional support
- Parenteral feeding options
- Central parenteral nutrition (CPN)
- Peripheral parenteral nutrition (PPN)

PPN
- Duration: Short term (in hospital use)
- Osmolarity: <650 mOsm/L
- Central parenteral nutrition (CPN)
- Peripheral parenteral nutrition
- Advantages: Bypass GI tract
- good for patient where enteral feeding is contraindicated (obtunded, comatose, anesthetized/ on respirator, severe GI dysfunction)
- Disadvantages: expensive, dedicated IV catheter required, risk of complications (metabolic, infectious & mechanical)

p.39

Plan - How to give gradual nutritional support to an anorexic patient
-Determine route & appropriate diet
- Enteral vs. parenteral
- Start at 25% RER given over 24 hours
- CRI vs. bolus ie. 3-6 times per day
- If using PN consider trickle feeding 5-15 % RER via NE tube
- Monitor frequently
- Gradually increase intake by 25% over following 12-24 hours – evaluate tolerance
- If well tolerated continue with incremental increase until full RER is achieved – 2-4 days
- If not tolerated stop at current feeding amount and give supportive care until patient is able to tolerate an increase
- Monitor patient – weight, TPR, auscult, assisted feeding site
- Monitor tolerance of diet
- Monitor for refeeding syndrome (q 24 h)
- Hypophosphatemia
- Hypomagnesemia
- Hypokalemia
- Decreased Thiamine

p.40

Additional considerations
Feeding tubes
- Ensure feeding amount & timing appropriate
- Usually 3-6 feedings/ day (2 hours interval between); 5-10 ml/kg stomach volume tolerance
- Once reached full RER adjust up/down in 10% increments to maintain weight stability
- Also consider
- Slurry – body temperature (not cold/hot), viscosity
- Relaxed – patient and provider – calm quiet patient after feeding
- Rate – slow over 10-30 minutes; watch for tolerance (lip smacking, drooling)
- Water – Before starting feed & following administration of feeding (5-10 ml) warm water ensure patency
- When to remove – depends on tube & patient voluntary oral intake

p.41

Additional considerations
Feeding tubes – going home
- GIVE OWNER WRITTEN INSTRUCTIONS
- Name of food (recipe), amount, feeding frequency, duration of tube feeding anticipated, monitor complications, offer oral feeding?
- OWNER SHOULD PRACTICE FEEDING WITH YOU ON DISCHARGE
- If patient is having severe diarrhea, vomiting, nausea
- Stop feeding – check slurry temp, rate of infusion, check placement
- Skip next meal
- Continue with following meal (same volume vs. last successful volume)
- Consider diet change

p.42

How to give nutritional support – diet options
- Diet selection based on patient needs
- Patient disease
- Route available
- Nutrient composition & energy density
- Availability in hospital
- Cost – in hospital vs. long term
- Liquid diets
- Critical care diets
- Blenderized commercial diet

p.43

Nutritional support diet options
- Liquid diets
- NE tubes & J tubes
- Options:
- Clinicare, Ensure, Vivonex, EmerAid
- Typically ~ 1 kcal/ml
- Consider nutrient content
- Balanced – long term feeding appropriate?
- Protein – feline patients
- Fat – canine pancreatitis
Image from: https://www.allvetsupply.com/clinicarerf 8oz.html
Image from: https://emeraid.com

p.44

Nutritional support diet options
- Convalescence or critical care diets
- E-tubes
- Liquid or canned – slurriable
- Purina Rx CN Critical Nutrition, RC Recovery RS, Hill’s Rx a/d, EmerAid, Clinicare
- Energy dense, palatable, nutrient dense, balanced
- Possible contraindications – fat intolerance, protein intolerance
Images from: https://www.chewy.com

p.45

Nutritional support diet options
- Blenderized commercial diet = Slurry
- E tubes & G tubes
- Canned or dry – Vet or commercial diet
- Choice for disease, cost
- Energy density variable
Image from: https://www.costco.com/Vitamix- Image from: https://www.brynmawrvet.com/prescription-pet-food/E320-Explorian-Blender.product.100387652.html

p.46

Nutritional support diet options
- How to make a slurry :
- Determine caloric density of the diet (on label kcal/gram)
- Pulse in high quality blender +/- water (dry 1st, record water used for recipe)
- Test through feeding tube until easily flows
- Measure total volume of slurry
- Total calories (kcal) = ___________ caloric density of slurry (kcal/ml)
- Total volume (ml)
Image from: https://www.costco.com/Vitamix- E320-Explorian-Blender.product.100387652.html

p.47

Complications of assisted feeding
- Metabolic
- Hyperglycemia, refeeding syndrome, hyperlipidemia
- Mechanical
- Tube obstruction, tube dislodgement, tube removal
- Infectious
- Aspiration pneumonia, stoma infection, septic peritonitis
- Patient
- Rhinitis, epistaxis, esophagitis, nausea, vomiting, diarrhea
Image from: https://irockdecals.com/boxer-dog-outline-decal-sticker/

p.48

Monitoring – hospitalized patients
- Monitor while in hospital and include in record
- Complete feeding orders
- Weight, body condition, muscle mass
- Goal - weight stability while in hospital
- If patient is underweight consider gradual increase of intake (~10% achieved) increase per day as tolerated until appropriate weight
- Feed intake & refusal
- Record intake clearly ex:
- 0 = ate none, 1 = ate 25% or less, 2= ate 26-50%, 3 = ate 51-75% , 4 = ate more than 75%
- Ensure patients are at least consuming RER

Feeding orders include:
- Type of food
- Amount
- Frequency
- Other (route, rate, etc.)
- What to do if refusal occurs
- Monitoring of intake

p.49

Monitoring
Feeding orders include:
- Type of food
- Amount
- Frequency
- Other (route, rate, etc.)
- What to do if refusal occurs
- Monitoring of intake
Images property of Dr. Wilson

p.50

Prevent malnutrition
- Investigation of the relationship between caloric intake and outcome in hospitalized dogs – multi-center study in dogs; Remillard et al. 2001
- Only 27% had intake >95% RER – don’t let this happen in your hospital
- Make sure your orders are clear and appropriate
- 22% - poorly written orders
- 34% - orders to withhold food
- Monitor patient intake and address inadequate intake quickly with appropriate nutritional support
- 44% - dogs refused to eat adequately

p.51

Helpful internet resources
- World Small Animal Veterinary Association (WSAVA) Global Nutrition Guidelines
- https://www.wsava.org/Guidelines/Global-Nutrition-Guidelines
- American College of Veterinary Nutrition
- https://acvn.org
- Online nutrition text: Small Animal Clinical Nutrition
- http://bookstore.markmorrisinstitute.org/t/digital-books/sacn5-chapters- downloadable

p.52

References
- Small Animal Clinical Nutrition 5th Ed. (Hand et al., 2010)
- Nutritional Management of Hospitalized Small Animals (Ed.: Chan, 2015)
- Nutrient Requirements of Dogs & Cats (NRC, 2006)
- Applied Veterinary Clinical Nutrition (Fascetti & Delaney, 2012)
- Manual of Veterinary Dietetics (Buffington et al., 2004)
- Canine and Feline Nutrition, A resource for companion animal professionals (Case et al., 2011)
- An investigation of the relationship between caloric intake and outcome in hospitalized dogs (Remillard et al., 2001)
- Current knowledge about the risks and benefits of raw meat-based diets for dogs and cats (Freeman et al., 2013)